Background and aim
Hepatocellular carcinoma (HCC) is the third cause of cancer-related mortality. α-fetoprotein (AFP) is not a highly sensitive marker for predicting HCC despite its high specificity. Serum Golgi protein-73 (sGP73) seems to be promising new marker. This study aimed at evaluating the role of sGP73 alone and in combination with AFP for diagnosing HCC.
Patients and methods
This study was conducted on 90 Egyptian patients who were equally divided into two groups. Group 1 included 45 patients with hepatitis C virus-related liver cirrhosis without clinical or radiological evidence of HCC, and group 2 included 45 patients diagnosed as having HCC by triphasic abdominal computed tomography. Serum AFP and GP73 were measured using enzyme-linked immunosorbent assay.
Results
A cutoff value greater than or equal to 40 ng/ml for AFP had a sensitivity of 51.1%, specificity of 97.8%, and area under the curve (AUC) of 0.802. sGP73 with a cutoff value greater than or equal to 1.4 ng/ml yielded a sensitivity of 75.6%, specificity of 97.8%, diagnostic accuracy of 86.7%, and AUC of 0.908. The combined use of AFP and sGp73 led to an increase in sensitivity to 84.4%, specificity to 95.6%, diagnostic accuracy to 90%, and AUC to 0.947.
Conclusion
The combined use of AFP and sGp73 could increase the sensitivity and specificity for HCC diagnosis.

Introduction
Heart failure (HF) among geriatric population is an eminent problem, and patient awareness of the disease and subsequent adherence to the treatment may decrease the burden of this serious problem.
Objective
The purpose of the study is to evaluate the effectiveness of medical as well as nursing teaching program on awareness and adherence among elderly patients with chronic HF.
Patients and methods
The study was carried out in the Internal Medicine Department of Assiut University Hospital. Total coverage sample of elderly patients included 100 patients from both sexes, and their age ranged from 60 to 75 year. The study was carried out in the Internal Medicine Department of Assiut University Hospital. Overall, three tools were used in this study: (a) patient interviewing sheet (pretest and post-test) tool consisting of two parts regarding demographic characteristic and medical data, (b) Atlanta HF knowledge test, and (c) adherence questionnaire.
Results
The main results yielded by the study proved a highly statistically significant difference between pretest and post-test regarding awareness and adherence for patients.
Conclusion and recommendations
This study concluded that the medical and nursing teaching program was effective for awareness and adherence of the patients. More follow-up studies are needed to improve awareness and adherence for older adult patients with chronic HF to prevent complications.

Background
The risk of chronic kidney disease stage 5 and its progression depend on the stage and the underlying diagnosis. Haemodialysis has become the long-term maintenance therapy for these patients. The interaction among interleukin-6 (IL-6), hepcidin and the iron exporter ferroportin is a major contributor to the iron-deficiency anaemia of chronic disease. The aim of the present study was to investigate the effects of polysulphone dialyzer membrane on serum IL-6 and hepcidin, including haemoglobin levels, in first-time patients undergoing five cycles of haemodialysis.
Patients and methods
Totally, 11 patients (male: five, female: six) were recruited for the present study after obtaining written informed consent. Their mean age was 57.4±13.4 years, and they were undergoing haemodialysis for the first time. Hepcidin, IL-6 and haemoglobin levels were determined before the first cycle and the fifth cycle and after the fifth cycle of haemodialysis. Pearson’s correlation coefficients were also determined.
Results and discussion
No statistically significant differences were observed before the first cycle and after the fifth cycle of haemodialysis in haemoglobin, IL-6 and hepcidin levels nor between pre-fifth and post-fifth cycle values, except for IL-6, which showed a significant mean reduction (P=0.04) from the pre-fifth cycle of 67.0 pg/ml to a mean value of 42.9 pg/ml (64.0% reduction). Analysis of variance showed no significant variation in the parameters studied, and no significant correlations between haemoglobin and IL-6, haemoglobin and hepcidin, and IL-6 and hepcidin were found.
Conclusion
In this short study of five-cycle haemodialysis, significant reduction in IL-6 with no significant change in hepcidin levels was found, even though severe anaemia was present. Kidney dysfunction probably results in decreased clearance of inflammatory markers and may not be improved by haemodialysis alone. Moreover, a different approach to reduce these markers is therefore warranted.

Context
Hypertension after menopause sets women up for an increased risk of negative cardiovascular outcomes. A variety of relaxation techniques exist, which aim to relieve stress and reduce blood pressure. Several studies have been conducted to demonstrate the role of several relaxation techniques in lowering the blood pressure in hypertensive patients.
Aim
The aim of this study was to determine the effect of relaxation techniques on postmenopausal hypertension.
Participants and methods
Forty postmenopausal hypertensive women were selected randomly from the outpatient clinic at El Agouza Hospital. They were divided randomly into two groups (A, B): group A was treated with antihypertensive drugs (captopril 25 mg twice daily) and relaxation technique sessions (each session 20 min, three times per week for 3 months), whereas group B was treated with antihypertensive drugs (captopril 25 mg twice daily) only. Blood pressure was evaluated before and after performing the program for both groups. Variables were compared using the unpaired t-test, whereas pairwise comparison (pretreatment vs. post-treatment) within the same group was performed using paired t-test.
Results
Group A, which was treated with antihypertensive drugs and relaxation techniques, showed a statistically highly significant difference (P<0.01) in both diastolic blood pressure and systolic blood pressure compared with group B, as the mean difference was 12.5 and 3.5, respectively, in the diastolic blood pressure of groups A and B and 15.25 and 6.75 in the systolic blood pressure in groups A and B before and after performing the program, respectively.
Conclusion
The practice of relaxation techniques was a very effective method in reducing blood pressure in postmenopausal women.

Background
Graves’ disease (GD) is an autoimmune disease characterized by hyperthyroidism secondary to circulating autoantibodies. Multiple factors contributed to its etiology, including genetic and environmental factors. The role of vitamin D is well-known in calcium metabolism and skeletal homeostasis. Vitamin D was shown to be a modulator in both innate and adaptive immunity. There is a link between vitamin D deficiency and various autoimmune diseases. The prevalence of vitamin D deficiency was reported to be common in patients with GD. Interestingly, vitamin D deficiency is found to be associated with higher thyroid volume in patients with newly-onset GD. However, vitamin D deficiency relationship with GD remains a controversial issue.
Objective
The objective of this study was to evaluate the effect of vitamin D supplementation in GD with and without ophthalmopathy.
Patients and methods
A randomized prospective study was conducted on 60 adult patients with GD aged 20–40 years. Group 1 comprised 20 patients with GD receiving a daily dose of 30 mg of methimazole alone. Group 2 comprised 40 patients with GD receiving the same dose of methimazole, supplemented with intramuscular injection of vitamin D3 200 000 IU/month for 3 months. Patients were followed up over a 3-month duration.
Results
There was hypovitaminosis D in all participants with a percentage of vitamin D deficiency (vitamin D level: <20 ng/ml) of 73.9% in male and 54.1% in female and a vitamin D insufficiency (vitamin D level: 20–29 ng/ml) of 26.1% in male and 45.9% in female. Vitamin D was significantly correlated with thyroid volume and degree of exophthalmos. On vitamin D supplementation, group 2 had significantly lower thyroid volume and better effect on the degree of exophthalmos.
Conclusion
Vitamin D supplementation for GD has a favorable effect on thyroid volume and on the degree of exophthalmos.

Background
Asthma is one of the most common chronic respiratory diseases. Despite advances in asthma management, acute exacerbations continue to occur and impose considerable morbidity and mortality on patients and constitute a major burden on healthcare resources.
Objective
This study aimed to determine the associations between bacterial infections and adult asthma exacerbations, together with detection of antibiotic resistance patterns in clinical practice.
Patients and methods
Sputa were collected from 60 adult asthmatic patients recruited from both Internal Medicine Department and Chest Disease Department and their critical care units during exacerbation attacks. Patients underwent thorough clinical examination, laboratory investigations, and pulmonary function tests. Bacterial isolates were identified using the standard diagnostic methods. Susceptibilities of the isolated bacterial strains were determined using disk diffusion method.
Results
Significant bacterial growth was detected in 47 (78%) patients. Single etiological agent was detected among 44 (73%) patients, whereas mixed infection was found in three (5%) patients. A total of 52 bacterial strains were isolated from our asthmatic patients. The predominant bacterial strains were as follows in decreasing order: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Klebsiella pneumoniae, Staphylococcus aureus, Acinetobacter baumannii, and Pseudomonas aeruginosa. Gram-negative bacilli constituted 52% (27 isolates) of the total bacterial isolates during the exacerbation attacks. Non-multidrug-resistant bacteria were 15 (30%) in number, 22 (44%) bacterial isolates were multidrug resistant, six (12%) bacterial isolates were extensively drug resistant, and seven (14%) isolates were pandrug resistant.
Conclusion
Acute exacerbation of asthma was associated with infection in most patients. Gram-negative bacteria and S. pneumoniae form a relevant part of the microbial pattern of exacerbation of asthma. Antibiotic resistance among bacterial strains remains a challenge for the management of asthma exacerbations in clinical settings.

Health-related quality of life in patients with common variable immunodeficiency switching from intravenous to subcutaneous immunoglobulin therapy

p. 77

Mona Al-Ahmad, Ahmed Maher, Jasmina NurkicDOI:10.4103/ejim.ejim_2_17

Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency disease (PID) among adults. CVID consists of two phenotypes – one in which infections are the characteristic and another in which impressive inflammatory and/or hematological complications also develop, including lymphadenopathy, splenomegaly, autoimmune cytopenias, enteropathy, and granulomatous disease. These phenotypes appear to be stable, are related to immunological and inflammatory markers, and are predictive of outcomes. Both subcutaneous immunoglobulin (SCIG) and intravenous immunoglobulin (IVIG) are equally effective for replacement therapy. No data are available about specific factors affecting the quality of life related to switching from IVIG to SCIG in the Arabian Gulf area. We present the case reports of three adult CVID patients, who were shifted from IVIG to SCIG by the US conversion method (1 : 1.5). We followed-up patients for clinical outcomes, side-effects, immunoglobulin G (IgG) trough levels, annual infection rate, and quality of life using questionnaires (RAND-36) over a 3-year period. Three patients (two females and one male), with a mean age of 26 years, had received IVIG [Gamunex-C (Grifols Therapeutics Inc., NC, 27709 USA) 10%; Grifols] treatment for an average duration of 4 years and had average IgG trough levels of 7.7±2.9 g/dl. Patients were shifted to SCIG [Subcuvia (Baxalta Innovation GmbH, Vienna, Austria) 10%; Baxter] for different reasons. SCIG was administered, using an infusion pump, under medical supervision at the hospital, on a weekly basis. The average IgG trough level on SCIG was 10.4±1.5 g/dl. The annual infection rate of pneumonias, sinusitis, otitis media, and others significantly declined after switching to SCIG in all three patients. However, while on IVIG treatment, some patients reported headache and malaise, but when on the SCIG treatment the reactions were mild and infusion site-related such as erythema, swelling, and itching. Remarkably, all patients were successfully switched to SCIG with significant decrease in the annual rate of infections and a favorable steady-state of serum trough levels of IgG. The use of SCIG was generally associated with notable improvement in physical, emotional, and social health.

Both chronic myeloid leukemia and essential thrombocythemia are part of the spectrum of myeloproliferative neoplasm. Therefore, considerable overlap may occur in the clinical manifestations, and hematological and molecular findings in some patients. We report here a case of a 45-year-old men who presented with thrombocytosis. Bone marrow aspiration yielded small megakaryocytes with hypolobulated nuclei and positive BCR-ABL rearrangement. A diagnosis of BCR-ABL+ essential thrombocythemia was made and imatinib was advised.

Epilepsy-like movements are observed immediately after the administration of fentanyl as well as its derivatives. Although the event has no serious outcomes, it is so worrisome that it has garnered the attention of many authors to publish case reports of such events. Despite the presence of cerebral lesions in some cases, epileptic focus cannot be attributed to such lesions. Radiological and electrophysiological studies have failed to reveal abnormal cerebral activity during such events. The reported activity is usually generalized tonic–clonic convulsions. Epileptic convulsive movements were observed with low doses of fentanyl and its derivatives. Previous studies on animals have supported the occurrence of such epileptiform movements in corresponding doses. Idiosyncrasy and narcotic-related muscle rigidity did not satisfactorily explain the seizures. Our case report represents the occurrence of epileptiform movements twice in and an old patient with no cerebral insult. The past history was epileptic activity under control with lamotrigine for last 2 years.